Docs or Insurers: Who's Steering the Ship?

by Fred N. Pelzman, MD

The other day I was sitting in my office, precepting residents during their practice session, when I got a high-priority message from the front desk staff through our electronic health record, flagged red to grab my attention. "Patient in podiatrist's office, needs a referral, or he will not be seen. Urgent, please fax immediately."

Well, the patient was there, he clearly had some reason to see a podiatrist, and this old image that I was a "gatekeeper" screening referrals has long ago faded away from our role as primary care providers.

I dutifully entered the order section in the patient's chart, typed "consult to podiatry," added an ICD-9 code of foot pain (since I had no idea what he was really seeing a podiatrist for), left the provider field empty since none had been provided to me, processed the referral, and sent it back to the front desk staff.

Not a long process, not a lot of work for me really, but what a waste of time.

Why did my saying that this person needed to see a podiatrist, when they were already seeing a podiatrist, really add much to the healthcare process? All it added was administrative hurdles, and lots of work for my staff. Lots of frustration for the patient, and probably lots of frustration for the podiatrist and his staff as well.

Another example: A patient I share with a cardiologist in our institution had seen him the day before for his advanced cardiomyopathy, and an echocardiogram done in his office raised the question about possible left ventricular thrombus. The cardiologist had ordered an additional echocardiogram with intravenous contrast, placed the order, and sent it to his office for processing. They discovered that although the cardiologist was in the insurance plan the patient had, he was not allowed to order this test for the patient, that it "had to come from the PCP".

The cardiologist's office called my office staff, and told them that I had to re-order the echocardiogram. This seemed like a lot of redundant work; I'm not adding a lot of value to the patient's care, and it's not really allowing me to practice medicine.

Now I know that insurers need these referrals, this electronic bookkeeping, this tracking of where their patients are going and what's being done for them, in the name of some theoretical cost savings and efficiencies from their point of view. But we clearly should be able to figure out a way to get this stuff done without involving the clinicians who are there to take care of patients.

The insurers are interested in taking care of "their" patients to ensure they get the best care possible, to ensure that we provide the best care possible, and we share those same goals.

Insurers collect massive amounts of data, and send us reports on how we are doing taking care of their patients, and every month they develop additional metrics, new ways of slicing the data, and send us endless reports about how well we were doing, or not doing, taking care of our patients.

A couple of years ago one of the major insurers got in touch with our practice and told us that they would like to come over to our office for a sit down, to talk about our patients and how we take care of them. When they arrived, the executive and his retinue of employees presented us with data that suggested that "we" were costing "them" a lot of money to take care of "their" patients.

We went over the data they had, which showed it was costing them several million dollars more per year to take care of the panel of patients we shared than they collected in premiums from those patients.

Despite the fact that it appeared that much of the cost was due to several patients with acute leukemia who had massive unavoidable costs, they firmly came down with the recommendation that we find ways to take care of their patients with less cost.

One of the recommendations was that they hire and put into place in our practice a care coordinator, explicitly for the purpose of looking at how we were taking care of "their" patients, and look for innovative ways to improve the care, efficiency, and hopefully lower their costs.

We had major issues about installing care coordinators in our practice who work for an employer outside of our institution and were, therefore, primarily answering to them, and also we were very worried about providing this care coordination to only a select group of our patients, literally excluding people based on their insurance status.

However, as we were in the early stages of our patient-centered medical home rollout, and we knew that we were going to be getting additional care coordinators into the practice, we figured we would find a way to work these personnel into our care coordination team plan.

As we have progressed through the stages of our patient-centered medical home, the role that insurers play in this entire process has been a fascinating one to observe. We know they have a vested interest, an almost purely financial one, in delivering care more efficiently and cheaply to patients.

But as primary care practitioners who want to do only the best for our patients, getting caught up in the cost question for care leads down some very tricky roads. Important, true, but cost to an insurer is not what you as a provider want to guide your care of patients.

We should welcome the insurers to the table, as we continue building the patient-centered medical home, but it's time we as practitioners and providers of care seize the reins, take control, and start making some rules of our own.

We are here to provide care for "their" patients, and ultimately we (hopefully) know best.

We understand that they're worried about fraud, over-spending, over-testing, over-referring, but hopefully we can work together to build a more patient-centered way of taking care of these patients as our healthcare model changes in the 21st-century.

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